27685
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
6.52
Facility
$443.56
Non-Facility
$681.71
Documentation Required
- Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage; such documentation does not guarantee coverage.
- Referenced guideline titled 'Medical Records Documentation Used for Reviews' for specifics on required documentation.
- When deciding coverage, the member specific benefit plan document must be referenced (the member specific plan governs in the event of a conflict).
- If applied to Medicare Advantage, determinations may rely on objective evidence-based rationale and applicable Medicare guidance (IOM Pub. No. 100-16, Ch. 4, §90.5); documentation should support applicability of such guidance.
Key Coverage Criteria
- Surgery of the ankle (including arthrodesis, arthroscopy, arthrotomy, and total joint replacement of the ankle) when medically necessary and when the member meets the applicable clinical coverage criteria referenced (InterQual® CP: Procedures: Arthrodesis, Ankle (Talotibial Joint); Arthroscopy, Surgical, Ankle; Arthrotomy, Ankle; Total Joint Replacement (TJR), Ankle).
- Ankle surgery to treat osteoarthritis when clinical criteria for surgical intervention are met.
- Ankle surgery to treat posttraumatic arthritis when clinical criteria for surgical intervention are met.
- Procedures listed in the policy procedure categories (Arthrodesis, Arthroscopy, Arthrotomy, Total Joint Replacement) when the member meets InterQual® clinical criteria (i.e., coverage tied to InterQual® criteria for those procedures).
3 Active Policies
UHC-POL-surgery-ankle — Surgery of the Ankle
UMR-POL-UMR-surgery-ankle — Surgery of the Ankle
SUREST-POL-SUREST-surgery-ankle — Surgery of the Ankle
Related Codes
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